A nurse in an outpatient clinic is assessing a middle adult client as part of a routine physical examination. The client's BP is 142/88 mm Hg, his body mass index (BMI) is 31, and he is a current smoker. The nurse should identify that this client has multiple risk factors for which of the following disorders?
Cardiovascular disease
Depression
Thyroid disease
Testicular cancer
The Correct Answer is A
The nurse should identify that this client has multiple risk factors for cardiovascular disease, such as hypertension, obesity, and smoking. These factors can increase the risk of atherosclerosis, coronary artery disease, stroke, and peripheral vascular disease.
Depression is wrong because it is not directly related to the client's physical examination findings. Depression may have other risk factors, such as genetics, stress, trauma, or substance abuse.
Thyroid disease is wrong because it is not directly related to the client's physical examination findings. Thyroid disease may have other risk factors, such as autoimmune disorders, iodine deficiency, or radiation exposure.
Testicular cancer is wrong because it is not directly related to the client's physical examination findings. Testicular cancer may have other risk factors, such as cryptorchidism, family
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Correct Answer is C
Explanation
- A hemorrhagic stroke is a type of stroke that occurs when a blood vessel in the brain ruptures and bleeds into the surrounding tissue. A common cause of hemorrhagic stroke is a cerebral aneurysm, which is a weak or bulging spot in an artery wall. When an aneurysm ruptures, it causes sudden and severe bleeding in the brain, which can damage brain cells and increase intracranial pressure. Symptoms of a hemorrhagic stroke include a sudden and severe headache, often described as "the worst headache of my life", followed by neurologic deficits, such as weakness, numbness, vision loss, speech problems, confusion, or loss of consciousness
- The other options are not correct because:
- History of neurologic deficits lasting less than 1 hr. This statement is incorrect because it describes a transient ischemic atack (TIA), which is a temporary interruption of blood flow to the brain that causes brief neurologic symptoms that resolve within 24 hours. A TIA is often a warning sign of an impending ischemic stroke, which is a type of stroke that occurs when a blood clot blocks an artery in the brain and reduces blood flow to the affected area.
- Maintains consciousness. This statement is incorrect because most clients with hemorrhagic stroke lose consciousness or have altered mental status due to the increased intracranial pressure and brain damage caused by the bleeding. The level of consciousness depends on the location and extent of the hemorrhage, but it usually deteriorates rapidly.
- Gradual onset of several hours. This statement is incorrect because hemorrhagic stroke usually has a sudden onset, unlike ischemic stroke, which may have a gradual onset over several hours or days. The onset of hemorrhagic stroke is often associated with physical exertion, emotional stress, or hypertension, which can increase the risk of aneurysm rupture.
Correct Answer is D
Explanation
The nurse should place a towel under the client's head to protect it from injury during the seizure. The nurse should also loosen any tight clothing, remove any objects that could harm the client, and maintain a patent airway.
Place the client in a prone position is wrong because it can compromise the client's breathing and increase the risk of aspiration. The nurse should place the client in a side-lying position after the seizure to facilitate drainage of oral secretions and prevent aspiration.
Holding the client's arms and legs still is wrong because it can cause injury to the client or the nurse. The nurse should not restrain or interfere with the client's movements during the seizure but rather ensure a safe environment and observe the seizure activity.
Leaving the client to get help is wrong because it can endanger the client's safety and well-being. The nurse should stay with the client during the seizure and call for assistance if needed, but not leave the client alone or unattended.
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